Living wills often mistaken for DNR orders in pre-hospital setting

Significant confusion and concern for patient safety exists in the pre-hospital setting due to the understanding and implementation of living wills and DNR orders. This confusion can be corrected by implementing a clearly defined code status into the living will, according to a study in the February edition of the Journal of Emergency Medicine.

“The living will, as it is created today, represents a clear and present danger to the healthy patient who has a critical illness like a heart attack,” said lead author Ferdinando Mirarchi, DO, medical director of the ED at Hamot Medical Center in Erie, Penn. “Individuals need to know what their living will says and understand how it could be interpreted.”

A living will is a document that states your wishes for healthcare treatment that would be used at a time in which you are terminal or in a persistent vegetative state and could not speak for yourself. A do-not-resuscitate (DNR) order states that you do not wish for lifesaving measures to be taken if you are in cardiac or respiratory arrest, in other words dead.

Mirarchi and colleagues sought to determine whether a living will impacts the type of care that patients receive before they reach the hospital. Researchers administered a three-part survey to 150 emergency medical technicians (EMTs) and paramedics at a regional emergency medical system educational symposium.

Part I assessed understanding of the living will and DNR orders. Part II assessed the living will's impact in clinical situations of patients requiring lifesaving interventions. Part III was similar to part II except a code status designation (full code) was incorporated into the living will. A full code means that all aggressive life saving interventions should take place.

There were 127 surveys completed, yielding an 87 percent response rate. The majority were male (55 percent) and EMTs (74 percent). The average age was 44 years and the average duration of employment was 15 years.

Researchers found that 90 percent of respondents determined after review of the living will that the patient’s code status was DNR and 92 percent defined their understanding of DNR as comfort care/end of life care.

When the living will was applied to clinical situations, it resulted in a higher proportion of patients being classified as DNR as opposed to full code. With the scenarios presented, this DNR classification resulted in a lack of or a delay in lifesaving interventions.

Incorporating a code status into the living will produced statistically significant increases in the provision of lifesaving care.

“The living will, due to its structure, is often misinterpreted as a DNR and therefore has the potential to compromise patient safety,” Mirarchi said. “Furthermore, DNR is understood to define comfort care/end of life care, which far exceeds its published definition and further exacerbates the patient safety risk.”